Transcription
Billing Manual1 Page
Introductory Billing Information . 5Billing Instructions. 5General Billing Guidelines . 5Paper Claim Submissions . 6Billing Codes . 6CPT Category II Codes . 7Encounters vs Claim. 7Non-Clean Claim Definition . 7Rejection versus Denial. 8Claim Payment . 8Claims Payment Information. 9Systems Used to Pay Claims . 9Claims for Long Term Care Facilities . 10Electronic Claims Submission. 10Paper Claim Submission . 10Basic Guidelines for Completing the CMS-1500 Claim Form (detailedinstructions in appendix): . 11Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) . 11Common Causes of Claims Processing Delays and Denials . 12Common Causes of Up Front Rejections . 12CLIA Accreditation . 13How to Submit a CLIA Claim . 13Claim Requests for Reconsideration, Claim Disputes and Corrected Claims . 15Provider Refunds . 17Third Party Liability / Coordination of Benefits . 17Billing the Member / Member Acknowledgement Statement . 18PA Health & Wellness Code Auditing and Editing . 18CPT and HCPCS Coding Structure . 19International Classification of Diseases (ICD 10) . 202 Page
Revenue Codes . 20Edit Sources . 20Code Auditing and the Claims Adjudication Cycle . 21Code Auditing Principles . 22Frequency and Lifetime Edits . 24Duplicate Edits . 24National Coverage Determination Edits . 24Administrative and Consistency Rules . 25Prepayment Clinical Validation. 26Inpatient Facility Claim Editing . 28Payment and Coverage Policy Edits . 28Claim Reconsiderations related to Code Auditing and Editing . 28Viewing Claim Coding Edits. 29Code Editing Assistant . 29Disclaimer . 29Other Important Information . 29Health Care Acquired Conditions (HCAC) – Inpatient Hospital . 29Reporting and Non Payment for Provider Preventable Conditions (PPCS). 30Non-Payment and Reporting Requirements Provider Preventable Conditions(PPCS) - Inpatient . 30Other Provider Preventable Conditions (OPPCS) – Outpatient . 30Non-Payment and Reporting Requirements Other Provider PreventableConditions (OPPCS) – Outpatient. 30Lesser of Language . 30Timely Filing . 31Use of Assistant Surgeons . 31Appendix I: Common HIPAA Compliant EDI Rejection Codes . 32Appendix II: Instructions For Supplemental Information. 32Appendix III: Instructions For Submitting NDC Information . 333 Page
Appendix IV: Claims Form Instructions CMS 1500 . 36Appendix V – Claims Form Instructons – Ub . 494 Page
INTRODUCTORY BILLING INFORMATIONBilling InstructionsPA Health & Wellness follows CMS rules and regulations for billing and reimbursement.General Billing GuidelinesPhysicians, other licensed health professionals, facilities, Long Term Support ServiceProviders, and ancillary providers contract directly with PA Health & Wellness for payment ofcovered services.It is important that providers ensure PA Health & Wellness has accurate billing information onfile. Please confirm with our Provider Relations department that the following information iscurrent in our files: Provider name (as noted on current W-9 form) National Provider Identifier (NPI) Tax Identification Number (TIN) Taxonomy code Physical location address (as noted on current W-9 form) Billing name and address 13-Digit PROMISeTM ID for each service location**In order to avoid possible delays in processing, providers must bill claims with all appropriateidentifiers validating that both the billing and rendering providers and their service locations areregistered in the state of Pennsylvania’s PROMISeTM system.ALL Billing and Rendering provider information will be subject to up front editing against thePROMISeTM system, and claims containing any non registered or inactive provider recordswill be rejected. Claims missing the required data will be returned, and a notice sent to theprovider, creating payment delays. Such claims are not considered “clean” and thereforecannot be accepted into our system.**All Providers and Servicing locations must be actively registered with PA-DHS in order forPA Health & Wellness to generate claims payment. Please validate program eligibility prior toclaims submission.We recommend that providers notify PA Health & Wellness 30 days in advance of changespertaining to billing information. Please submit this information on a W-9 form. Changes to aProvider’s TIN and/or address are NOT acceptable when conveyed via a claim form.Claims eligible for payment must meet the following requirements: The member must be effective on the date of service (see information below on5 Page
identifying the member), The service provided must be a covered benefit under the member’s contract onthe date of service, and Referral and prior authorization processes must be followed, if applicable.Payment for service is contingent upon compliance with referral and prior authorizationpolicies and procedures, as well as the billing guidelines outlined in this manual.When submitting your claim, you need to identify the member. There are three ways toidentify the member: The PA Health & Wellness member number found on the member ID card or theprovider portal. The Medicaid Number provided by the found on the member ID card or the providerportal.Paper Claim SubmissionsPA Health & Wellness only accepts the CMS 1500 (2/12) and CMS 1450 (UB-04) paper claimforms. Other claim form types will be rejected and returned to the provider.Professional providers and medical suppliers complete the CMS 1500 (2/12) form andinstitutional providers complete the CMS 1450 (UB-04) claim form. PA Health & Wellnessdoes not supply claim forms to providers. Providers should purchase these from a supplier oftheir choice. All paper claim forms are required to be typed or printed and in the original redand white version to ensure clean acceptance and processing. All claims with handwritteninformation or black and white forms will be rejected. If you have questions regardingwhat type of form to complete, contact PA Health & Wellness at 1-844-626-6813.Billing CodesPA Health & Wellness requires claims to be submitted using codes from the current version of,ICD-10, ASA, DRG, CPT4, and HCPCS Level II for the date the service was rendered. Theserequirements may be amended to comply with federal and state regulations as necessary.Below are some code related reasons a claim may reject or deny: Code billed is missing, invalid, or deleted at the time of service Code is inappropriate for the age or sex of the member Diagnosis code is missing the 4th or 5th digit as appropriate Procedure code is pointing to a diagnosis that is not appropriate to be billed asprimary Code billed is inappropriate for the location or specialty billed Code billed is a part of a more comprehensive code billed on same date of service6 Page
Written descriptions, itemized statements, and invoices may be required for non-specific typesof claims or at the request of PA Health & Wellness.CPT Category II CodesCPT Category II Codes are supplemental tracking codes developed to assist in the collectionand reporting of information regarding performance measurement, including HEDIS.Submission of CPT Category II Codes allows data to be captured at the time of service andmay reduce the need for retrospective medical record review.Uses of these codes are optional and are not required for correct coding. They may not beused as a substitute for Category I codes. However, as noted above, submission of thesecodes can minimize the administrative burden on providers and health plans by greatlydecreasing the need for medical record review.Encounters vs ClaimAn encounter is a claim which is paid at zero dollars as a result of the provider being pre-paidor capitated for the services he/she provided our members. For example; if you are the PCPfor a PA Health & Wellness member and receive a monthly capitation amount for services,you must file an encounter (also referred to as an ““proxy claim”) on a CMS 1500 for eachservice provided. Since you will have received a pre-payment in the form of capitation, theencounter or “proxy claim” is paid at zero dollar amounts. It is mandatory that your officesubmits encounter data. PA Health & Wellness utilizes the encounter reporting to evaluate allaspects of quality and utilization management, and it is required by HFS and by the Centersfor Medicare and Medicaid Services (CMS). Encounters do not generate an Explanation ofPayment (EOP).A claim is a request for reimbursement either electronically or by paper for any medicalservice. A claim must be filed on the proper form, such as CMS 1500 or UB 04. A claim will bepaid or denied with an explanation for the denial. For each claim processed, an EOP will bemailed to the provider who submitted the original claim. Claims will generate an EOP.You are required to submit either an encounter or a claim for each service that you render to aPA Health & Wellness member.Non-Clean Claim DefinitionNon-clean claims are submitted claims that require further documentation or developmentbeyond the information contained therein. The errors or omissions in claims result in therequest for additional information from the provider or other external sources to resolve orcorrect data omitted from the bill; review of additional medical records; or the need for otherinformation necessary to resolve discrepancies. In addition, non-clean claims may involveissues regarding medical necessity and include claims not submitted within the filingdeadlines.7 Page
Rejection versus DenialAll claims must first pass specific minimum edits prior to acceptance. Claim records that do notpass these minimum edits are invalid and will be rejected or denied.REJECTION: A list of common upfront rejections can be found listed below. Rejections will notenter our claims adjudication system, so there will be no Explanation. A REJECTION isdefined as an unclean claim that contains invalid or missing data elements required foracceptance of the claim into the claim processing system. The provider will receive a letter ora rejection report if the claim was submitted electronically.DENIAL: If all minimum edits pass and the claim is accepted, it will then be entered into thesystem for processing. A DENIAL is defined as a claim that has passed minimum edits and isentered into
policies and procedures, as well as the billing guidelines outlined in this manual. When submitting your claim, you need to identify the member. There are three ways to identify the member: The PA Health & Wellness member number found on the member ID card or the provider portal. The Medicaid Number provided by the found on the member ID card or the provider portal. Paper Claim .
